The Perception of Professional Nurses About the Introduction of the National Health Insurance (NHI) in a Private Hospital in Gauteng, South Africa

Received: February 20, 2018 Revised: May 9, 2018 Accepted: May 15, 2018 Abstract: Introduction: Based on concerns raised by professional nurses working in a private hospital that hinge on financial implication of the NHI, the state of public health sector and implications of the NHI to the South African health system prompted the need to determine their perceptions on the introduction of the NHI in a private hospital in Gauteng province, South Africa.


INTRODUCTION
The awareness of National Health Insurance (NHI) policy implementation is very low amongst health professionals [1 -3]. National health insurance, a concept introduced in the South African health system is being piloted since 2012 in the 11 districts of the Provinces in South Africa to ensure that all citizens have access to quality and affordable health care regardless of their socio-economic status [4,5]. The NHI is perceived differently by professional nurses [1 -3] [6][7][8]. It is a financing system conceived to provide all South African citizens with necessary quality health care irrespective of whether they are employed or not [9]. Taking into consideration that the current health system funding is two-tiered hence the NHI seeks to close this gap by improving the public-sector health delivery, reduce the high cost of the private sector and improve the population's life expectancy with an impact in reduction of mortality and morbidity rates as documented on Western European countries outcome of the Universal Health Coverage [10].
The NHI policy implementation is motivated by policy reform of health care services informed by the World Health Organisation [11]. The policy reform encompasses major health policy change aimed at improved health care delivery [12].
The South African features of apartheid as characterised by fragmentation, racial segregation, lack of primary healthcare strategy and private healthcare, provided for the minority. This was a turning point in the current democratic era, pioneering for the change in the health system [13]. The Constitution of South Africa (1996) advocates for the rights of access to health care services which should be promoted, fulfilled, protected and respected by the Government [14]. The National Department of Health 2030 vision on Universal Health care coverage also advocates for the accessibility of the health care services irrespective of the employment status that is unlimited and supported by the shared funds [15]. Hence, the National Department of Health in its White Paper advocates for the structure of financing of central hospitals to be changed, to make these the best institutions as national assets and as training platforms nationally and internationally [16].
The NHI is to be rolled out in three phases over a 14-year period from 2012, focusing on the improvement of health care delivery in public health institutions and making sure that private health care consultation fees are reduced. It also hinges on improving the quality of health and life expectancy. These will be achieved by ensuring that the following initiatives are implemented: the municipal ward based primary health care; integrated school health programme; district clinical specialist and contracting of private health practitioners [16]. In addition, the National Department of Health outlined the National Core Standards as set up by the Office of Health Standard Compliance (OHSC) that need to be achieved ensuring that NHI provides quality care for all South Africans [16]. The OHSC is functional for quality assurance and accreditation of hospitals and health facilities to make sure that they qualify for the NHI funding [17]. The 2 nd phase (2017/2018-2020/2021) of piloting is based on establishing the NHI fund and finalising legislation, hence at this stage, there is no payment by citizens towards the NHI [18]. Different countries' Health Insurance Systems are structured according to their unique needs, Canada is primarily sponsored by the government with one mandatory health plan. Germany is government sponsored with 200 health plans, Singapore has a mandatory subsidized self-insurance and the United States of America has no mandatory plan and it is employer sponsored [19].
Nurses are the heart of service delivery and are the most recognisable force of health care in South Africa. The practice of nursing is grounded in standards and ethical values and it is supported by a system of professional regulation, thus determining the scope of practice for every level of nursing, identifying desirable standards of practice and competencies and to bring these to the attention of every nurse [20]. This is enshrined in the regulations relating to the scope of practice of persons who are registered or enrolled under the Nursing Act, 33 of 2005 [20]. Therefore, all professional nurses whether in public or private sector are bound by the nurse's scope of practice in South Africa and are expected to be compliant with the National Core Standards. As such, the nurses' perception of the implementation of the NHI will highlight the intervention measures necessary for its successful implementation. Therefore, the objective of this study was to determine the perceptions of professional nurses about the introduction of the NHI in a private hospital in Gauteng Province, South Africa.

Design of the Study
A contextual study using a qualitative, exploratory and descriptive design.

Population and Sample
A sample of 18 willing professional nurses working in a private hospital in Gauteng was purposively and conveniently recruited out of a pool of 249 so as not to generalise the findings. Available studies were conducted in public institutions where the NHI is piloted hence in this study private hospital professional nurses were recruited. The sample size was determined by data saturation.

Instrument
Participants were interviewed using a semi-structured individual interview schedule with open-ended questions to determine their perception on the introduction of the NHI and its implication to the South African health system.

Validity and Reliability
Data quality was ensured by employing measures of trustworthiness which are; credibility, dependability, confirmability and transferability as outlined by Brink et al. (2012).

Data Collection
Interviews were conducted using open ended questions, probing and prompting employed to elicit more data. The interviews were audio recorded using a digital recorder.

Ethical Clearance
Ethical approval was obtained from the University of Fort Hare (REC-270710-028-RA Level 1). Permission was obtained from the private institution where the study took place. Informed consent was obtained from all participants prior to data collection.

Data Analysis
Creswell's qualitative technique of data analysis was applied [21]. This entails preparing data; coding; developing themes, categories and subcategories. Table 2 outlines the findings in themes, categories and sub-categories. Perceptions of professional nurses about the introduction of the NHI shared more or less same sentiments, though based on differing views. However, some did not seem to have a grasp of the NHI context. Table 2 gives us the structure of how data collected was analysed, coded and systemically developed into themes, categories and subcategories leading to presentation of results.

Perceptions About the NHI
Most participants indicated that the NHI is about equal distribution of health resources to benefit all South Africans, as one participant indicated: "NHI is about equal distribution of health services to benefit the communities that are not able to pay for their own health care and are not to be segregated". They also commented on the perception that it will bridge the gap between the current two-tiered health systems, as stated by one participant: "it is a system that will bridge the gap between the two-tiered health systems".
There were concerns raised about the state of public health sector, shortage of health personnel and inadequate resources, contributing to the perception that it might not succeed, as one participant remarked: "Public sector will always have staff shortages and inadequate resources, although there will be improved access to health facilities, it will definitely be negatively compounded by these problems". Another participant commented thus: "Nursing care in our public hospitals is very poor, patients stay longer due to complications. I don't know how the government is going to help with this, and the most qualified staff are moving overseas".
Scepticism with regard to NHI's affordability was identified based on countries perceived as having a high unemployment rate. On the issue of payment to ensure affordability, a participant stated that "I think it's going to be better to make it a flat rate if we are to pay", "NHI will be affordable if the government allocates a certain amount for a province ".
There were other perceptions as one mentioned: "When we talk about insurance we talk about coverage, you've been covered for your health, for example those well to do people can have medical aid to cover their health (sic)". Another participant commented: "Why must I worry about the NHI? I am working in a private sector, NHI is a government thing, it does not have to apply to us". Yet, one participant bluntly stated: "I do not know much about NHI and have no interest as such to seek information".

National Core Standards
Responses were centred on patients' rights, leadership and governance, operational management and infrastructure. Participants hope that NHI will improve health care service delivery as indicated by one participant: "With this NHI the government will better the status of the health institutions". "the public health care sector will improve its health standards and most people will literally use public hospitals more than the private hospitals." The questionable personal and professional integrity of health professionals was seen as one of the major factors violating patients' rights, as expressed by a participant: "It will make sure that patients are respected and treated fairly with some dignity and privacy, though staff need to change their negative attitudes which, ja it's gonna (sic) take a long time".
Doubts about the improvement of clinical support services were portrayed, especially with the constant shortage of medications, such that one participant expressed the following opinion: "My main concern is the shortage of medications because even when these mobile clinics go to rural areas they always have a shortage of medication, patients go back home without treatment". Equipment issues raised were relayed as such: "If they have to implement that (NHI), they have to plan, start by training to have enough staff, have enough equipment and everything so that they can match private sector, otherwise having a NHI with no equipment or if it's not cared for will not have good results".
How health care institutions and funds will be managed under the NHI was asked by a participant: "Who will be managing this NHI?" And another participant remarked: "They must show accountability and ensure that resources are available and adequate". There were concerns that not all health care institutions will be accredited for NHI due to dilapidated infrastructure, as verbalised by a participant: "Some health care sectors have buildings that are dilapidated while a few are being renovated in preparation for the implementation of NHI". Another participant highlighted the fact that: "Management must make sure that buildings are maintained and safe for patients and employees."

Private Practice
Great concerns were raised on the viability of the private hospitals and the medical health schemes after the full implementation of the NHI, depending on its success or failure, as comprehensively stated by one participant that: "The implication will be that, being in the private sector per se, if the health care systems and health care in hospitals in the government sector is improved, most people will literally use the public hospitals more than the private sector. With the fact that as being in private health care we will lose clients to the public sector, with a decrease in clients the private sector down the line there will be a loss of profits and value. They won't be able to sustain us if we lose clients. I for one will be forced to leave the private sector, that's one thing that might happen".
However, participants expressed a need for a joint effort between private and public health sector to form one health system, therefore, sharing the burden of health care. Conflicting ideas on whether to continue or stop contributions towards private medical aid schemes are evident, hence most participants indicated that if the NHI works they will opt for it and stop contributions towards medical aid schemes.

Readiness for NHI
Most participants had no idea of what is happening at the pilot sites. This is perceived to be the result of poor communication, as indicated by one participant: "you know, their communication is poor, it shows that things are not progressing well in those sites". However, another participant remarked in support of pilot sites, stating that: "transformation policies need to be piloted first before they can be rolled throughout the country".

General Views on NHI
Perceived lack in communication on the part of policy makers and the government were seen as stumbling blocks in facilitating information dissemination, awareness and marketing of the NHI. Hence, participants lack a comprehensive understanding of the whole concept of NHI. "Give us information about this NHI, update us on what is planned and implemented and give us feedback".
"Professional nurses like to be spoon-fed (sic) with information, if they pay attention to issues pertaining to health and the NHI they will be able to know about the progress, therefore, they must look for information themselves".
Funding issues are of great concern as participants perceive that it will have a huge financial impact on those who prefer to maintain their medical aid schemes and still contribute towards the NHI. "Who is going to be paying for this NHI?" asked a participant. "I was not aware that all workers are supposed to contribute towards the NHI fund. This has a hefty financial impact…and already we are paying so much tax" lamented another participant.
How the NHI funds will be managed was another sore point for most participants: "who will be managing these funds?" "Well, I hope for the sake of the NHI passing, funds will be distributed evenly across institutions according to need".

DISCUSSION
Professional nurses' perceptions about the introduction of the NHI yield a lot of mixed feelings and concerns about its implementation. How it was perceived by professional nurses gives an indication that there is a lot that needs to be done to ensure that it is supported and there is enough information and transparency about the whole process of implementing the NHI policy.
However, it was reassuring to elicit that most were optimistic about the NHI ensuring that its principles like: improved access to health care, equity, social solidarity, affordability, efficiency, effectiveness and appropriateness will be covered. Challenges that are currently experienced in the public health care sector like shortage of human resources and inadequate equipment and health care resources led to others doubting the feasibility of the successful implementation of the NHI. There was some scepticism with regard to whether the NHI will be affordable based on limited trust towards the current government and there were fears that it will have a financial impact on those that will be eligible to contribute towards the NHI.
The perception of the context of NHI as a general insurance indicates that there is some confusion about what NHI stands for and as such, McIntyre suggests that the NHI interpretation has created some confusion with the word insurance, thus he prefers the use of the concept Universal Health Coverage (UHC) [22]. Identified from participants was that there exists a knowledge gap with regards to the subject on NHI, which could be due to not having access to or time to read about current trends in the health sector.
Participants' responses were also centred on National Core Standards which include patients' rights, clinical support, leadership and governance, operational management, facilities and infrastructure. Most participants hope that the health needs of patients will be taken into consideration and care given in totality, which will contribute to positive outcomes for the whole population including the wellbeing of health professionals. On the contrary, this could lead to challenges experienced currently being unresolved, for example long waiting queues, delays in surgical procedures due to long waiting lists exacerbated by an increase in the number of patients.
Staff negative attitudes were perceived as a deterrent to patients accessing health care services, thus violating their rights to dignity. In other words, it is an indication that health care professionals with negative attitudes do not have personal and professional dignity. When analysing factors raised on the National Core Standards, participant's concerns are genuine, these professional nurses left the public sector at different times and they do not see any improvements in the sector from the time they left until now. Participants are part of the communities, they have access to the public health sector and they observe the environment when they accompany their next of kin for consultations and treatments in the public health sector, thus their observations and experiences are plausible.
Some scepticism on the improvement of clinical support services was portrayed by participants, especially about the availability of medications and shortages which negatively impact on the wellbeing of patients' recovery and uncontrolled chronic illnesses, causing more and severe complications. Poor management of equipment which compromises patient safety and wellbeing and an increase in litigations for the health sector. There are uncertainties and doubts about the NHI improving the status of the public health sector, as it currently deters public confidence. Therefore, how health institutions will be managed under the NHI will determine the effectiveness and the success of its implementation. These findings are consistent with other reports [3].
NHI fund management concerns were brought about by a lack of trust in health institutions, based on media reports on the mismanagement of funds and irregular expenditures. Concerns about human resources were valid as health professionals have left the country in droves, with huge implications for the health system and those remaining to render health care. The perceived implications of staff shortages will be compounded by a perceived influx of patients.
Health care institutions must be accredited for NHI implementation in compliance with the Office of Health Standards Compliance. The fact that some public health care institutions are renovated and some are still in their dilapidated state gives the perception that the NHI still has a long way to go prior to its full implementation throughout the country [3].
Perceptions of private practice extrapolated into two categories: the private health care sector and medical aid schemes. The private health care sectors' professional nurses expressed different views about policy makers taking unilateral decisions concerning policy making on policies which are supposed to be implemented by nurses. However, another perception was raised that professional nurses are passive and do not participate in platforms created for them to air their views and debate issues that concern them directly, especially those relating to policy development.
Participants expressed a need for a joint effort between the public and private health sectors to forge ahead in creating one health system. However, this notion was disputed by private sector stakeholders [23]. The universal coverage does not necessarily mean a single-tiered health system [23]. The vision is to see Public-Private Partnerships (PPP) which share the burden of health care.
There is some eagerness to learn more about the NHI. Participants indicated that they support the concept but need to be exposed to more information and there should be more transparency with regard to the NHI implementation processes as supported by the study in Nigeria [24].
The inability to make choices on whether to keep private medical aid while also contributing towards NHI or just have NHI funding, poses a dilemma to some participants. However, they indicate that this will be determined by the full implementation of the NHI and its outcome. Concerns about the future of the medical aid schemes and the private health sector viability will be determined by the success of NHI implementation.
Pilot sites are bench markers that should give an indication of whether the implemented NHI policy has a positive impact on the population or not. Its outcome is important to be able to review strategies for implementing the NHI throughout the country. There is an outcry that not all stakeholders are consulted about the implementation of NHI in pilot sites and that there is no transparency with regards to outcomes. Even those who are working on pilot sites, have no idea of the processes that are being implemented in their own hospitals [8]. There are still challenges in the pilot phase marked by uneven progress across the districts and lack of adequate infrastructural improvement [4,25]. Communication is the main key to increase awareness on any developing policy process and its implementation. However, most participants indicate a lack of communication on the part of policy developers and the government hence their lack of comprehensive knowledge pertaining to the implementation of the NHI policy and its context in general. With advancements in technology and social media awareness through communication and the dissemination of information could easily be achieved [25].
Concerns about funding caused an outcry, as some participants did not anticipate that they will have to pay for NHI as well as their own private medical aid scheme if they chose to retain it. However, participants do support the proposed NHI, the main concern is how much and how are they going to contribute towards the NHI. The funding principles supported by independent assessment will be of great value at this formative stage [18]. Therefore, the funding and costing impact will be determined by full implementation detail. There are other views that NHI's current format is unsustainable unless there is economic growth [18].

LIMITATIONS
This study was conducted among professional nurses working in a private hospital in Gauteng Province, South Africa. Therefore, its findings will neither be generalised to include other professional nurses working in other private hospitals, public health sector nor to the entire Gauteng Province or other provinces.

Public Health
For a strong public health system, co-ordination of health services is essential in order to foster collaboration between public and private sector in sharing the burden of diseases.

Management and Policy Makers
The government must recommission closed nursing colleges to improve human resources. Setting of clear guidelines on dissemination of information with regard to new policies. Involve the Department of Education with regard to teaching NHI basics at schools.